Approximately 1,900 individuals who contribute to hospital quality improvement (QI) programs attended the inaugural American College of Surgeons (ACS) Quality and Safety Conference, July 21−24 at the New York Hilton Midtown, NY. The rapid growth of ACS Quality Programs in recent years prompted the expansion of the College’s Annual National Surgical Quality Improvement Program (ACS NSQIP®) Conference to include a more comprehensive look at not only ACS NSQIP Adult and Pediatric, but also the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®), the Children’s Surgery Verification (CSV) Quality Improvement Program, and the Surgeon Specific Registry (SSR).
With the theme of Achieving Quality: Present and Future, the conference featured nine interactive preconference workshops, five specialty-specific tracks, 12 general sessions, 37 breakout sessions, and nine specialty-specific and resident abstract sessions (see related sidebar, page 79, for a list of the winning abstracts). According to Clifford Y. Ko, MD, MS, MSHS, FACS, Director of the ACS Division of Research and Optimal Patient Care (DROPC), the conference was designed to provide attendees with insights into innovative processes to approach the evolving health care quality landscape and improve patient safety. “As leaders in the quality and safety arena, we must all continue to challenge ourselves to take the quality of care we provide to the next level,” Dr. Ko said.
ACS Quality Programs
Attendees had the opportunity to learn about new and existing initiatives, products, and services that the ACS offers to assist surgical professionals with quality improvement (QI) efforts.
Each conference attendee received a copy of the new ACS quality manual, Optimal Resources for Surgical Quality and Safety. The manual is intended to serve as a resource for surgical leaders seeking to improve patient care in their institutions, departments, and practices. Topics covered in the manual include the domains and phases of care, the role of the Surgical Quality Officer, peer and case review, the institutional infrastructure for QI, privileging and credentialing, patient-centered culture, data analytics, and other factors that influence the quality of care at health care institutions.
A key point made in Optimal Resources for Surgical Quality and Safety is that surgery is no longer considered an episodic event, with the surgeon acting as “the captain of the ship,” according to ACS Executive Director David B. Hoyt, MD, FACS. It is a multiphase, multidisciplinary treatment process, each stage of which affects the others and the final outcome. Across all five phases of surgical care—preoperative evaluation, immediate preoperative, intraoperative, postoperative, and postdischarge—the surgeon bears the ultimate responsibility for patient care, Dr. Hoyt said.
The registry of the future
The notion that a surgeon’s actions throughout the delivery of surgical care determine the end result is as old as the ACS. “Dr. [Ernest Amory] Codman had a vision 100 years ago that surgeons should keep track of their results and use that information for a variety of purposes. I think we’re finally getting to a point where we’re accepting that responsibility,” Dr. Hoyt said. Surgeons of the future will need a means of collecting and analyzing their data and benchmarking their performance to meet a range of regulatory demands, he noted.
To help surgeons meet these expectations, the ACS has partnered with QuintilesIMS to create what Dr. Hoyt calls “the registry of the future.” The new registry platform will have a single data warehouse system to store all ACS quality registry data. As a result, users eventually will be able to incorporate relevant data across individual ACS Quality Programs, including ACS NSQIP, into the SSR. The foundation of this platform, the reconstructed SSR, launched earlier this year.
Dr. Hoyt noted that the transition to the new SSR platform has had some rough spots. “What we’ve learned in this transition is that it’s very important to determine how a registry of this type supports the actual workflows,” he said. Dr. Hoyt said that the ACS and Quintiles are working to fix every problem that users have encountered. Amy J. Sachs, Senior Manager, Registry, DROPC, provided details on the project and its status.
QI is reliant on the quality team’s ability to collect data, analyze risk-adjusted outcomes, obtain provider feedback, and engage in QI planning, according to Bruce L. Hall, MD, PhD, MBA, professor of surgery and health care management; fellow, Center for Health Policy, Washington University; and vice-president and chief quality officer, BJC Healthcare, St. Louis, MO. The College’s flagship QI program, ACS NSQIP, provides 698 participating adult hospitals and 101 pediatric hospitals in 11 countries with the data they need to uncover and classify events and develop an action plan. “Participating hospitals know where they stand—as outliers or deciles—and know the benchmarks,” Dr. Hall said.
To get started on the QI journey, a quality officer will need to have the hospital’s Semi-Annual Report (SAR) from ACS NSQIP, access to the ACS NSQIP platform, and patient medical records, Dr. Hall said. Different institutions undertake this process for different purposes—to meet institutional imperatives, analyze worrisome trends over times, identify outliers, and so on. Whatever the reason, Dr. Hall said it is important to have an action plan that describes the purpose, rationale, specific aims, and anticipated outcomes.
DROPC staff provided details on specific elements of ACS NSQIP and how they can be used for QI. Mark E. Cohen, PhD, Senior Statistician/Data Analyst, described the risk-adjustment process and the ACS NSQIP Surgical Risk Calculator; Kristopher Huffman, MS, Statistician, explained how to use the SAR and Site Summary Reports; Yaomong Liu, Statistician, spoke about outcomes and inclusion filters used in ACS NSQIP Adult modeling; and Lynn Zhou, PhD, Statistician, gave an overview of the ACS NSQIP Adult Participant Use Data File.
Jacqueline Saito, MD, MSCI, FACS, a pediatric surgeon at St. Louis Children’s Hospital, MO, and a Surgeon Champion, spoke about ACS NSQIP Pediatric SARs, noting that ACS NSQIP Pediatric can guide hospital QI by identifying high-risk procedures. When looking at their SARs, pediatric hospitals should “focus not just on outcomes alone, but couple high-quality care with efficient resource utilization,” because children generally have better outcomes than adult or geriatric patients, Dr. Saito said.
Many hospitals have found that participation in an ACS NSQIP collaborative can be helpful in improving quality of care for a specific specialty or across hospitals in a state or region. Karl Y. Bilimoria, MD, MS, Director, Illinois Surgical Quality Improvement Collaborative (ISQIC) and Anthony D. Yang, MD, MS, FACS, Associate Director, described the components of the ISQIC’s successful QI program, including the development and implementation of a quality and safety curriculum.
In addition, speakers described the following: how the Northern California ACS NSQIP Collaborative hospitals were able to reduce readmissions, how the Texas Alliance for Surgical Quality Collaborative Project implemented evidence-based guidelines to reduce surgical site infection, and how the Upstate New York Surgical Quality Initiative used the Enhanced Recovery After Surgery (ERAS) program to reduce length of stay and readmissions at participating hospitals.
The ACS has partnered with the Johns Hopkins Medicine Armstrong Institute, Baltimore, MD, to launch the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR). This program is modeled on the ERAS protocols that have been effectively used to improve outcomes in colorectal and other procedures. Stacy A. Brethauer, MD, FACS, associate professor of surgery, Cleveland Clinic Lerner College of Medicine, OH, described ERAS as representative of “a paradigm shift in perioperative care in two ways: it reexamines traditional practices and replaces them with evidence-based best practices when necessary; and it is comprehensive, covering all areas of the patient’s journey through the surgical process.”
Elizabeth C. Wick, MD, FACS, a colorectal surgeon at Johns Hopkins, said the goals of the ISCR program are to help hospitals achieve measurable improvement in patient outcomes in five surgical areas—colorectal, orthopaedics, emergency general surgery, bariatrics, and gynecology—reduce health care utilization, and improve the patient care experience. ISCR participation is open to all hospitals in the U.S. and its territories. Hospitals may participate in one or more of the five cohorts, and each cohort study will last one year.
Dr. Brethauer described a related initiative that is being conducted under the aegis of MBSAQIP, known as ENERGY (Employing New Enhanced Recovery Goals for Bariatric Surgery). The goal of ENERGY, which began pilot testing in November 2016, is to decrease variability and improve value by maintaining homeostasis in bariatric surgery patients throughout the perioperative period. ENERGY is being tested at 37 bariatric surgery centers.
The mission of MBSAQIP is to “achieve surgical QI through rigorously collected, risk-adjusted outcomes,” said John M. Morton, MD, MPH, FACS, FASMBS, Chair, MBSAQIP Committee for Metabolic and Bariatric Surgery. According to Teresa Fraker, MS, RN, Program Administrator, MBSAQIP, ACS DROPC, the MBSQIP Data Registry is being overhauled to enhance the user experience for metabolic and bariatric surgical clinical registrars and the data and analytics experience for accredited centers. Work completed to date includes brainstorming for the registry design, reviewing each variable in the registry, conducting on-site visits at MBSAQIP-accredited centers, and improving logic checks to ensure more accurate data capture.
As Diana L. Diesen, MD, FACS, assistant professor, department of surgery, University of Texas Southwestern Medical Center, Children’s Health Dallas, said, “Children are not little adults. Not all children can be treated the same.” She explained the different treatment modalities that need to be used in pediatric surgery in the preoperative, intraoperative, and postoperative phases of care.
In recognition of the unique needs of pediatric patients, the College has developed the CSV program. Keith T. Oldham, MD, FACS, CSV Chair, said the vision behind the CSV program is that “every child in need of surgical care in North America today will receive this care in an environment with resources optimal for his/her individual needs.”
“A large portion of children’s surgical care is provided in nonspecialized environments in the U.S. today,” he added. “A specialized environment is associated with better clinical outcomes for some patients,” especially neonates and children needing operations for congenital heart conditions and trauma, as well as some relatively simple pediatric surgical problems, such as appendicitis in children ages five and younger.
The overriding principle of the CSV is tiered accreditation for hospitals, much like the system used to accredit trauma centers; that is, Level III centers would be accredited only to provide low-risk procedures by single specialty, whereas Level I centers would be verified as meeting the program’s standards for complex procedures and diseases that require multidisciplinary care. The program officially launched in January.
“Starting in 2012, 10,000 people will turn 65 each day. By 2030, 20 percent of the population will be over 65 years old, and by 2050, nearly 20 million people will be older than 85 years of age,” said Ronnie A. Rosenthal, MS, MD, FACS, Co-Principal Investigator, the Coalition for Quality in Geriatric Surgery (CQGS) Project. “More than 50 percent of people older than 65 years old will require some surgical procedure in the remainder of their lifetime.”
With this awareness in mind, the ACS and other stakeholders established the CQGS with funding from The John A. Hartford Foundation. The goals of the CQGS are to engage stakeholders, set standards, develop measures that matter to patients, develop a verification process to ensure quality, educate patients and providers, pilot the program, and launch a Geriatric Surgery Quality Campaign. Stakeholder organizations represent patients and families, advocacy and regulatory bodies, health care professionals, and medical and surgical specialties.
The CQGS has conducted field visits at 11 hospitals in seven U.S. cities, said Dr. Rosenthal, Co-Chair of the CQGS Standards Subcommittee. More than 100 hospital administrators, quality and safety team members, frontline providers, care transition team members, and patient navigators participated in interviews. The CQGS found that all of these providers share the perception that older adults require special care, but they were unclear what that meant. The subcommittee recently began beta testing standards of care.
Keynote Address: Resilience
According to Susan D. Moffat-Bruce, MD, PhD, FACS, professor of surgery, division of thoracic surgery, and professor of biomedical informatics and molecular virology, immunology, and medical genetics, The Ohio State University, Columbus, resilience is the ability to experience a significant loss and find a way to make something good come of it. An individual who exemplifies resilience, she said, is Blake Haxton, JD, who lost both of his legs to necrotizing fasciitis.
During his keynote address, Mr. Haxton described his journey from going to the local hospital’s emergency department with debilitating swelling and redness in his right leg to reclaiming his identity. After more than three months of intensive treatment and rehabilitation, Mr. Haxton had defied the odds and proven his body’s resilience throughout the ordeal. The question now was, what would someone who had previously identified as “athletic, tall, healthy, independent, attractive, confident, and humble,” do without both his legs?
He found himself asking “Where does my value come from?” He learned that ultimately, “essential worth is intrinsic and unearned.” He went back to school and earned a law degree. He even returned to the sport he loves—rowing—emerging a champion. He was named the 2016 U.S. Rowing Male Athlete of the Year and is in training for the 2020 Paralympic games. As he looks to the future, he asks himself three questions: “Is it knowable? Is it controllable? What can I do about it right now?”
Other hot topics
Speakers at the conference addressed a number of hot issues in health care, including health policy, opioid abuse, patient-reported outcomes (PROs), and disparities in care.
Health care professionals are increasingly affected by regulatory policies. According to Frank G. Opelka, MD, FACS, Medical Director, Quality and Health Policy, ACS Division of Advocacy and Health Policy, the ACS used to take a reactionary position on policy issues. “Our principle actions now are more proactive,” Dr. Opelka said. “Define a problem and bring policy solutions forward. Then work the politics to effect our principles, policies, and positions.”
The key policy development affecting physicians at present is implementation of the Quality Payment Program (QPP) established under the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act. The QPP offers two pathways to participation—the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model. Most Medicare-participating surgeons will be seeking reimbursement through MIPS, at least initially. Payment under MIPS has four components: Quality (reported outcomes), Advancing Care Information (electronic health record [EHR] meaningful use), Clinical Practice Improvement Activities (CPIA), and Cost.
To comply with the QPP, “clinicians need consistent measurement infrastructure using advanced analytics, multiple data sources, and registries—all of which represent a much larger data ecosystem than the EHR alone can offer,” Dr. Opelka said. That’s where the College’s new database platform enters the value-based care equation. The SSR has been approved as a QPP MIPS-Qualified Entity for 2017, which means it can be used to fulfill the Quality and CPIA MIPS requirements, he noted.
A hot topic in the lay and professional media is the opioid epidemic. Jonah J. Stulberg, MD, PhD, MPH, assistant professor of surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, noted that most states have passed legislation or are considering bills that establish prescription drug monitoring programs (PDMPs). Other states are making safe disposal easier to limit abuse by individuals who access opioids from people who have stopped taking the medications.
Dr. Stulberg suggested that surgeons rethink pain control, making greater use of NSAIDS, acetaminophen, Cox-2 inhibitors, gabapentin, nerve blocks, and alternative modalities such as massage and physical therapy as first-line methods of pain control. For patients needing more pain relief, surgeons can advance to oral opioids, reserving Class IV opioids for the most extreme cases.
According to Andrea Pusic, MD, MHS, FACS, professor of plastic and reconstructive surgery, Memorial Sloan-Kettering Cancer Center, New York, PROs “are reports that come directly from patients about how they function or feel in relation to their health condition and its therapy.” Patients specifically provide feedback on their experience, postoperative quality of life, and symptoms. PROs are important because traditional outcome measures, such as length of stay, mortality, urinary tract infection, and surgical site infection (SSI), “don’t capture the full range of ways that patients are affected by disease and treatments,” Dr. Pusic said. “PROs represent the missing piece.”
Adil H. Haider, MD, MPH, FACS, Vice-Chair of the ACS Committee on Health Care Disparities, said, “[Surgeons] have unconscious preferences or implicit biases that impact how we interact with patients.” To counteract these biases, surgeons need to become “culturally dexterous.” Dr. Haider elaborated, “Cultural dexterity is the adept use of mental and physical skills to understand and adapt to each unique patient in order to provide patient-centered care.”
Dr. Haider provided a “checklist for cross-cultural communication,” which, among other responsibilities, calls upon surgeons to humanize their patients, identify and monitor conscious and unconscious biases, respond thoughtfully to patient complaints, and hold their institutions accountable for providing culturally dexterous care.
For any QI effort to succeed, it has to evolve in a culture that accepts change, acknowledges shortcomings, uses data to find strengths and weaknesses, and demonstrates the same resilience that Mr. Haxton showed in overcoming necrotizing fasciitis. Two cultural changes that surgical teams have experienced in recent years include a greater emphasis on process improvement and checklists.
According to Lillian Kao, MD, MS, FACS, professor of surgery at The University of Texas Health Science Center at Houston (UTHealth), and chief, division of acute care surgery, McGovern Medical School at UTHealth, “There is a well-defined, step-by-step, iterative process for performing QI.” The first step is to develop a problem statement that indicates who is affected, when the problem was discovered or arose, where the problem is occurring, the frequency of the problem, what happened, and what didn’t happen. Next, set SMART (Specific, Measurable, Attainable, Realistic, Timely) goals, identify stakeholders, and achieve buy-in. The next step is brainstorming, followed by problem solving. One approach to PI Dr. Ko discussed is DMAIC—define, measure, analyze, improve, control.
Checklists have become ubiquitous in hospitals as a means of ensuring that precautions are taken to ensure patient safety. KuoJen Tsao, MD, FACS, The Children’s Fund Distinguished Professor in Pediatric Surgery, department of pediatric surgery, UTHealth, discussed how to use surgical safety checklists to achieve and sustain QI. He said the surgical safety checklist should serve as an opportunity for communication in the OR and should be used to confirm, not dictate, that safety precautions have been taken. “Not all checklist items may apply to all cases, but all cases benefit from items within the checklist,” Dr. Tsao said.
Culture is dependent on the attitudes and values of the people functioning in it. The disruptive surgeon is anathema to a culture of safety, according to Oscar Guillamondegui, MD, FACS, professor of surgery, vice-chair, quality, safety, and risk prevention, department of surgery, Vanderbilt University School of Medicine, Nashville, TN. He defined disruptive behaviors as actions that “undermine a culture of safety and prevent or interfere with an individual’s or group’s work or ability to achieve intended outcome.” Such behaviors range from verbally or physically aggressive actions, to passive-aggressive behaviors, such as intentional miscommunication and condescending tone, to failure to follow institutional guidelines and protocols.
Rachel R. Kelz, MD, MSCE, FACS, associate professor of surgery, University of Pennsylvania, Philadelphia, encouraged workplaces to develop a “culture of companionate love.” In this environment, emotions are encouraged and people care about each other. Workplaces that have this culture have more engaged employees, improved patient outcomes, and a greater likelihood of being recommended by caretakers.